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News and updates from today's Perioperative Medicine conference

Today's conference focuses on improving and enhancing perioperative medicine with a focus on high risk surgical patients and those with comorbid conditions following the 2015 report by the Royal College of Anaesthetists.Following the chairs introduction, Dr David Shipway Consultant Physician Imperial College Healthcare NHS Trust opens the day with a presentation on Focusing on the high risk patient with complex needs: Delivering proactive care for older people undergoing surgery, looking at:

“We know that these postop complications are predictive of mortality, so again itis not surprising to see that older people have higher mortality rates than younger. This is true across surgical populations and has been further demonstrated in the first patient set to be reported by NELA.”

“What we are seeing is an ever-increasing population of more elderly patients being referred for surgery. The association between ageing and comorbidity is now well established with rising comorbidity closely linked with age. What is also interesting is that 3 or more coexisting diseases is a strong predictor of postoperative mortality.”

“I am sure that you are all familiar with the fact that frailty as a term describes a syndrome of decreased physiological reserve across multiple organ systems. We all know what happens to things like GFR and vital capacity as we age, but equally other organs systems which are not so easily measured or defined also lose their functional reserve, meaning that smaller physiological insults can result in decompensation. So in the case of a period of hypotension, that may easily result in AKI, but if one considers how that is enough o disturb the function of an organ like the kidney, hopefully it’s easy to consider that it might also result in a ‘acute brain injury’, ie post-op delirium…And when complex neurophysiological processes like walking and upright balance are sitting on a knife edge, you can see how small instances can result in bigger functional deterioration which prevent mobility and rehab.”

“In summary, we have a building evidence base for where care can be improved for older patients undergoing surgery, and especially for those undergoing cancer treatment. Furthermore, there is building UK and international support for new ways of approaching older patients with malignant surgical disease, who as we have heard have not only age, but physiological changes, frailty and multi-morbidity complicating the clinical picture and surgical gold standard treatment.”

“In a survey, conducted by David Alcorn, the vast majority of the sprs recognised that their training in the needs of complex older people is inadequate, they recognise that they often need medical advice and struggle to access it and almost all want closer collaboration…Its not just the sprs who express such opinions but a variety of stakeholders who were surveyed by the RCS also recognised the need for closer collaboration between surgical and geriatric medicine teams to improve coordination of care for older surgical patients”

“What is good is that we are starting to consider these issues and starting to recognise the need for collaborative working between surgeons, anaesthetists and geriatricians. A number of the recnt reports have invariably come up with statements such as these.... And this poses us geriatricians with a challenge – how do we put surgical liaison models into practice”

“Enhanced recovery everyone has seen this is the “Team Sky” approach – lots of little changes (some big) leading to marked Improvements”

“Perioperative Medicine – lots of little steps, coming together to deliver what is Best for the high-risk patient – deciding who is a high risk patient is hard. The principles of preoperative medicine should work for all patients?”

“My remit is delivering a patient pathway fro before, during and after surgery and deciding how do we move from Enhanced recovery to Perioperative Medicine. I need to think about how do we cater for all high risk patients regardless of specialty – emergency and elective surgery”

“Perioperative Pathways – which patients should we do this for? Is it only for high-risk? Or can the same pathway be used for all? yes I think it can.”

Before – we had no anaesthetists present at pre-assessment, patients are flagged up to consultants or to those of us who have some pre-assessment sessions. High risk patients were flagged up and further decisions are then made on further tested or referrals. Meeting are the arranged and the results are uploaded to the clinical Portal

“What can be improved? – involve the cardiologists, not for an echo, but to see if anginal and antihypertensive Tx can be improved. CPEX testing? Introducing an exercise programme?”

“Exercise programme – Breast cancer patients have already started this and have been give something similar to a fitbit. They are highly motivated young people and there has been a high uptake so far. Colorectal cancer patients are offered walking/exercises classes at the point of diagnosis. They are also offered diet and alcohol advice and referred to smoking cessation clinics on the same day. Most people are taking this up to improve the out comes of there operations. These all start long before pre-assessment (so benign cases may get 10-12 weeks of healthy living)”

“Involve the cardiologists – we now ask them to PLR our high risk patients – we find out before a case if the patient is a fluid responder…respiratory, renal, CNS and diabetic disease can all be approached in the same way. Obesity is a bigger problem”

“Diabetic Control – we have introduced a new diabetic protocol whereby each drug is treated, short-acting insulins are usually given half their dose. This protocol has improved outcomes with less complications, less cancellations, less hypoglycaemias (and high glucose), much less insulin sliding scales and the whole of Glasgow is now adopting the protocol. Since starting this we have only has 2 cases of hypoglycaemia in more that 2 years”

“NELA – All emergency laparotomies get Sugammadex, over 90% go to HDU, EPOCH means we always prescribe fluids for afterwards. Mortality has dropped since the first 6 months (17.4% to 8.7%)”

“Emergencies will be getting a new Patient Pathway soon with goals for days post-op and incorporating data collecting and risk scoring”

“ER patients now all get EPOCH stickers for post-op fluids”

In conclusion to his presentation David stated:

“You don’t find out anything until you audit yourself. Then change.”

“The high risk patient need care and common sense.”

Dr David Alcorn's biography

I have been a consultant anaesthetist for nearly 13 years and have seen considerable changes in our hospital and trust. I was an ITU consultant for 9 years and while that role was eventually not for me, the experience I gained was hugely beneficial for changing the way we look at the sick or high risk patient. We were the only hospital in Scotland to be included in the Improving Surgical Outcomes Group and were leaders when Greater Glasgow took up ERAS, having been involved in setting up Paisley’s ERAS service in 2005. We were the last hospital in the trust to get an ERAS nurse. I have been involved in the setting up of the Scottish database for ERAS and remain an adviser to the Scottish Government on this. Recently this has become the NERCI (National Enhanced Recovery in Colorectal Initiative) and I have played a very active part in helping to set this up.

This presentation highlights from a patient perspective what some of the most important needs of surgical patients are, both those intrinsic to the individual/s and those deriving from social factors, which can be equally disabling. By ensuring that the patient is supported by the whole perioperative MDT in different ways to share the issues which are most relevant to their lives, patient experience and patient outcomes are more likely to be optimised.

Neil Betteridge's biography

After working for most of my professional life representing the interest of patients in the UK and Europe from within the third sector, I now run my own company, Neil Betteridge Associates. This offers high level, patient focused advice on a range of issues affecting the lives of patients, especially people with long-term conditions. During 2015 for example, I developed and introduced a new patient involvement strategy for the Royal College of Physicians.